Download Data Collection

FOR INTERNAL USE ONLY AS NEEDED:
Patient Name:________________________
Unique study ID # _____________________
Patient ID Number:_______________________
Institution:_______________________________
(IMPORTANT NOTE : For the purposes of data collection and PROOVIT follow-up, each
individual vascular injury requires SEPARATE data entry (Unique ID). Utilize ID # XXX-1 format
for first injury in individual patient, followed by XXX-2, XXX-3 etc for subsequent injuries in the
same patient).
Specific vascular structure injured (check ONLY ONE for each individual entry):
Cervical
___ Common carotid artery
___ Internal carotid Artery
___ External carotid artery
___ Vertebral artery
___ Internal jugular vein
Extremity (upper)
___ Brachial artery
___ Axillary artery
___ Radial artery
___ Ulnar artery
___ Basilic vein
___ Axillary artery
Extremity (lower)
___ Common, superficial or deep femoral artery
___ Common, superficial or deep femoral vein
___ Popliteal artery
___ Popliteal vein
___ Anterior tibial artery
___ Posterior tibial artery
___ Peroneal artery
Torso
___ Innominate artery
___ Innominate vein
___ Subclavian artery
___ Subclavian vein
___ Intra-thoracic right common carotid artery
___ Intra-thoracic left common carotid artery
___ Descending thoracic aorta
___ Abdominal aorta
___ Infra-renal inferior vena cava
___ Retro-hepatic inferior vena cava
___ Common, external or internal iliac arteries
___ Celiac artery
___ Common hepatic artery
___ Splenic artery
___ Superior mesenteric artery
___ Superior mesenteric vein
___ Portal vein
___ Renal artery
___ Renal vein
___ Common, internal or external iliac artery
___ Iliac vein
MORE THAN ONE VASCULAR INJURY? (Not including concomitant venous injury) ___Yes ___No
______________________________________________________________________________________________________
Demographics
Age (years): _____
Gender (M/F): _____
Type of Injury:
Key past medical history elements (Check all that apply):
___ Chronic Kidney Disease (baseline creatinine ≥ 2 mg/dL)
___ Insulin dependent diabetes mellitus
___ Condition requiring full anticoagulation (warfarin or other agent)
___ Blunt
___ Penetrating
___ Mixed blunt and penetrating
Mechanism of Injury
___ Motor vehicle crash ___ Pedestrian versus auto ___ Gunshot
___ Stabbing ___ Fall
___ Industrial accident ___ Athletic injury
___ Explosionn ___ Other:_______________
Injury Scores
Injury Severity Score (ISS):
_____
Abbreviated Injury Scores (AIS) for each body region
Head: ____ Abdomen: ___ Chest: ___ Extremity: ___
Trauma Presentation and Diagnostic Measures:
Admission systolic blood pressure:
Admission Glasgow Coma Score (GCS):
Admission labs:
Hemoglobin (g/dL):
pH:
Lactate (mmol/L):
INR:
____________
____________
__________
__________
__________
__________
Application of prehospital tourniquet:
___ Yes ___ No
Hard signs of vascular injury present
(hemorrhage, expanding hematoma,
ischemia)
___ Yes ___ No
Soft signs of vascular injury present
(wound proximity, reduced pulses,
fracture / dislocation pattern)
___ Yes ___ No
Doppler pressure measurement for
extremity injury (ABI or IEI) obtained?
Tourniquet type:______________
Estimated tourniquet time:_______
___ Yes ___ No ___ N/A Value of ABI or IEI: ______
Mangled Extremity Severity Score (MESS)
for extremity calculated?
___ Yes ___ No
If calculated, MESS value: ______
Modality utilized to make DEFINITIVE diagnosis of vascular injury
___ Operative exploration
___ Contrast-enhanced computed tomography / angiography (CTA)
___ Duplex ultrasound
___ Conventional contrast angiography in interventional radiology
___ Conventional contrast angiography in operating room (to include hybrid OR/IR)
Injury type as defined by diagnostic modality utilized:
___ Transection
___ Occlusion
___ Partial transection or flow limiting defect (e.g. dissection or intimal flap)
___ Pseudoaneurysm
___ Other:_______________________________
Acute, Damage Control and Definitive Management
Observation of vascular injury
(i.e. no operation of intervention)
____ Yes ____ No
Adjunctive Medical therapy for vascular injury
observation utilized
Anti-hypertensive (beta blockade or vasodilator)
Antiplatelet therapy (ASA or plavix)
Anticoagulation (IV or sub Q heparinoids)
Other:
____
____
____
____
____
Initial open operative management of vascular injury
Use of damage control techniques
Ligation of vascular injury
Primary traumatic amputation
Use of temporary vascular shunt
(Argyl, Javid, Sundt, other)
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No Type: _______________
Estimated dwell time of shunt:________________
Definitive open vascular repair at initial operation
Primary repair
End-to-end repair
End-to-side repair
Lateral suture closure of vessel wall
Autologous vein interposition or bypass graft
Contralateral greater saphenous vein
Other vein type
Synthetic graft interposition or bypass
Expanded ePTFE (Gortex)
Dacron
Other synthetic
Other type of vascular repair
____
____
____
____
____
____
____
____
____
____
____
____
____
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
____
____
____
____
____
____
____
____
No
No
No
No
No
No
No
No Type:_______________
No
No
No
No Type: _______________
No Type:________________
Concomitant vein injury encountered
during arterial repair
____
Management of concomitant vein injury undertaken ____
Repair lateral venorrhaphy
____
Repair interposition vein graft
____
Ligation of concomitant vein injury
____
Other management type
____
Yes
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
____
No
No
No
No
No
No Type:________________
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
No
No
No
No
No
Type: _______________
Systemic anticoagulation utilized during initial operation or vascular repair
____ Yes ____ No
Concomitant nerve injury encountered during operative repair
____ Yes ____ No
Concomitant orthopedic fracture encountered during operative repair
____ Yes ____ No
Extremity fasciotomies performed intra-operatively
____ Yes ____ No
If Fasciotomiew were performed, please characterize their role / conduct (Select one most appropriate):
____ Therapeutic at time of initial procedure
____ Therapeutic delayed (second procedure)
____ Prophylactic at time of initial procedure
____ Prophylactic delayed (at time of second procedure)
Definitive ENDOVASCULAR repair of vascular injury?
Hospital location where endovascular repair performed:
Interventional radiology suite
Operating room using mobile C-army fluoroscopic unit
Operating room with fixed fluoroscopic system
Access site for endovascular repair
Femoral artery
Brachial artery
Both femoral AND brachial artery
Other
Covered Stent graft repair of vascular injury
Stent graft product:__________________________
Stent graft diemensions:______________________
Number of covered stents used:________________
Bare metal stent repair of vascular injury
Stent graft product:__________________________
Stent graft diemensions:______________________
Number of stents used:_______________________
Coil or other material embolization
Type of material used:___________
Was systemic anticoagulation utilized during
endovascular repair?
Access site complication requiring operative intervention
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____
____
____
____
____
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
No
No
No
No Type:______
No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
Intra-operative / intra-procedural variables (for both open and endovascular interventions)
Time from injury to initial operative or endovascular intervention:
Duration of operative or endovascular procedure
Fluid requirements during operation / procedure:
Crystalloid
____________ ml
Non-blood colloid
____________ ml
Packed red blood cells ____________ units
Plasma
____________ units
Platelets
____________ units
Cryoprecipitate
____________ units
Was tranexamic acid given at any point during management
Was factor VIIa given at any point during management
Lowest recorded pH during operation / procedure:
____________ minutes
____________ minutes
____ Yes ____ No
____ Yes ____ No
_______________
Lowest recorded temperature during operation /procedure: _______________
Was clinically apparent or laboratory demonstrated
coagulopathy encountered during operation / procedure:
____ Yes ____ No
Intra-operative / procedure mode of determining adequacy of management strategy:
____ No intra-operative assessment
____ Presence or absence of palpable pulse
____ Continuous wave Doppler
____ Arteriography
____ Other: ______________
Need for immediate revision of intra-operative repair due to any cause
____ Yes ____ No
Post-operative variables
Pos-operative ICU stay required
Length of ICU stay
Ventilator days
Continuous infusion of vasopressors required
during first 24 hours post-operative / post-procedure?
Neosynephrine
Dopamine
Levophed / Noriepinephrine
Vasopressin
Epinephrine
____ Yes ____ No
______________ Days
______________ Days
____
____
____
____
____
____
Yes
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
____
No
No
No
No
No
No
Total units of packed red blood cells required in initial 24 hours of hospital stay: _______ Units
Post-operative or post-procedure
therapeutic anticoagulation utilized?
____ Yes ____ No
Intravenous heparin
____ Yes ____ No
Subcutaneous low molecular weight heparin
____ Yes ____ No
Oral warfarin
____ Yes ____ No
Other
____ Yes ____ No Type:_________________
Post-operative or post-procedure
antiplatelet therapy
____ Yes ____ No
Aspirin
____ Yes ____ No
Plavix
____ Yes ____ No
Other
____ Yes ____ No Type:_________________
Was anticoagulation or antiplatelet therapy continued
until discharge
____ Yes ____ No
In-hospital outcomes
Hospital length of stay
Vascular injury or repair evaluated again during
hospitalization by other than physical exam
CTA
Duplex
Injured extremity index or ABI
_______ days
____
____
____
____
Yes
Yes
Yes
Yes
____
____
____
____
No
No
No
No
MRI or MRA
Contrast arteriography
Need to re-operate or re-intervene on definitive
management choice during initial hospitalization
Failure of non-operative management
Thrombosis of definitive vascular repair
Flow limiting stenosis of vascular repair
Pseudoaneurysm of vascular repair
Infection resulting in need to re-operate
Type of re-operation or re-intervention
Open operative revision
Endovascular revision
Other
Stroke related to vascular injury or injury repair
Amputation of extremity in which limb salvage
was attempted
Bowel resection from ischemia in area
of vascular injury
In-hospital death
____ Yes ____ No
____ Yes ____ No
____
____
____
____
____
____
Yes
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
____
No
No
No
No
No
No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No Type:__________________
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
Patient discharged on therapeutic anticoagulation
for vascular repair
____
Intravenous heparin
____
Subcutaneous low molecular weight heparin ____
Oral warfarin
____
Other
____
Yes
Yes
Yes
Yes
Yes
____
____
____
____
____
No
No
No
No
No Type:_________________
Patient discharged on antiplatelet therapy
Aspirin
Plavix
Other
Yes
Yes
Yes
Yes
____
____
____
____
No
No
No
No Type:_________________
____
____
____
____